Best practice considerations on the assessment of robotic assisted surgical systems: results from an international consensus expert panel.

BACKGROUND: Health technology assessments (HTAs) of robotic assisted surgery (RAS) face several challenges in assessing the value of robotic surgical platforms. As a result of using different assessment methods, previous HTAs have reached different conclusions when evaluating RAS. While the number of available systems and surgical procedures is rapidly growing, existing frameworks for assessing MedTech provide a starting point, but specific considerations are needed for HTAs of RAS to ensure consistent results. This work aimed to discuss different approaches and produce guidance on evaluating RAS. METHODS: A consensus conference research methodology was adopted. A panel of 14 experts was assembled with international experience and representing relevant stakeholders: clinicians, health economists, HTA practitioners, policy makers, and industry. A review of previous HTAs was performed and seven key themes were extracted from the literature for consideration. Over five meetings, the panel discussed the key themes and formulated consensus statements. RESULTS: A total of ninety-eight previous HTAs were identified from twenty-five total countries. The seven key themes were evidence inclusion and exclusion, patient- and clinician-reported outcomes, the learning curve, allocation of costs, appropriate time horizons, economic analysis methods, and robotic ecosystem/wider benefits. CONCLUSIONS: Robotic surgical platforms are tools, not therapies. Their value varies according to context and should be considered across therapeutic areas and stakeholders. The principles set out in this paper should help HTA bodies at all levels to evaluate RAS. This work may serve as a case study for rapidly developing areas in MedTech that require particular consideration for HTAs.

Grateful Patient Philanthropy: A Challenge to Organizational Ethics.

An examination of organization development in health care reveals a pattern of increasing reliance of academic medical centers toward new sources of revenue in support of operations. This trend is partly in response to the reduction of traditional funding sources such as public appropriations and tuition. Clinical income from faculty earnings and hospital transfer payments have supplanted heritage funding sources and are now predominantly institutional transactions rather than physician-patient interactions. Grateful patient philanthropy can be viewed as moving toward transactional status, with challenging ethical questions for the involved physician and patient as institutional control increases.

Costs of Biopsy and Complications in Patients with Lung Cancer.

PURPOSE: To describe the distribution of diagnostic procedures, rates of complications, and total cost of biopsies for patients with lung cancer. PATIENTS AND METHODS: Observational study using data from IBM Marketscan® Databases for continuously insured adult patients with a primary lung cancer diagnosis and treatment between July 2013 and June 2017. Costs of lung cancer diagnosis covered 6 months prior to index biopsy through treatment. Costs of chest CT scans, biopsy, and post-procedural complications were estimated from total payments. Costs of biopsies incidental to inpatient admissions were estimated by comparable outpatient biopsies. RESULTS: The database included 22,870 patients who had a total of 37,160 biopsies, of which 16,009 (43.1%) were percutaneous, 14,997 (40.4%) bronchoscopic, 4072 (11.0%) surgical and 2082 (5.6%) mediastinoscopic. Multiple biopsies were performed on 41.9% of patients. The most common complications among patients receiving only one type of biopsy were pneumothorax (1304 patients, 8.4%), bleeding (744 patients, 4.8%) and intubation (400 patients, 2.6%). However, most complications did not require interventions that would add to costs. Median total costs were highest for inpatient surgical biopsies ($29,988) and lowest for outpatient percutaneous biopsies ($1028). Repeat biopsies of the same type increased costs by 40-80%. Complications account for 13% of total costs. CONCLUSION: Costs of biopsies to confirm lung cancer diagnosis vary substantially by type of biopsy and setting. Multiple biopsies, inpatient procedures and complications result in higher costs.

Patient-centered medical homes in Louisiana had minimal impact on Medicaid population's use of acute care and costs.

The patient-centered medical home model of primary care has received considerable attention for its potential to improve outcomes and reduce health care costs. Yet little information exists about the model's ability to achieve these goals for Medicaid patients. We sought to evaluate the effect of patient-centered medical home certification of Louisiana primary care clinics on the quality and cost of care over time for a Medicaid population. We used a quasi-experimental pre-post design with a matched control group to assess the effect of medical home certification on outcomes. We found no impact on acute care use and modest support for reduced costs and primary care use among medical homes serving higher proportions of chronically ill patients. These findings provide preliminary results related to the ability of the patient-centered medical home model to improve outcomes for Medicaid beneficiaries. The findings support a case-mix-adjusted payment policy for medical homes going forward.

Breast cancer surgery volume-cost associations: hierarchical linear regression and propensity score matching analysis in a nationwide Taiwan population.

BACKGROUND: No outcome studies have longitudinally and systematically compared the effects of hospital and surgeon volume on breast cancer surgery costs in an Asian population. This study purposed to evaluate the use of hospital and surgeon volume for predicting breast cancer surgery costs. METHODS: This cohort study retrospectively analyzed 97,215 breast cancer surgeries performed from 1996 to 2010. Relationships between volumes and costs were analyzed by propensity score matching and by hierarchical linear regression. RESULTS: The mean breast cancer surgery costs for all breast cancer surgeries performed during the study period was $1485.3 dollars. The average breast cancer surgery costs for high-volume hospitals and surgeons were 12% and 26% lower, respectively, than those for low-volume hospitals and surgeons. Propensity score matching analysis showed that the average breast cancer surgery costs for breast cancer surgery procedures performed by high-volume hospitals ($1428.6 dollars) significantly differed from the average breast cancer surgery costs of those performed by low-/medium-volume hospitals ($1514.0 dollars) and that the average breast cancer surgery costs of procedures performed by high-volume surgeons ($1359.0 dollars) significantly differed from the average breast cancer surgery costs of those performed by low-/medium-volume surgeons ($1550.3 dollars) (P < 0.001). CONCLUSIONS: The factors significantly associated with hospital resource utilization for this procedure included age, surgical type, Charlson co-morbidity index score, hospital type, hospital volume, and surgeon volume. The data indicate that analyzing and emulating the treatment strategies used by high-volume hospitals and by high-volume surgeons may reduce overall breast cancer surgery costs.

Financial implications of increasing medical school class size: does tuition cover cost?

INTRODUCTION: In 2006, the Association of American Medical Colleges (AAMC) issued a recommendation that medical schools increase the supply of physicians by 30% to meet the patient needs of the new millennium. OBJECTIVE: To provide financial analysis of the cost of increasing class size. METHODS: To determine the financial consequences of increasing medical student enrollment and in the absence of nationally published cost data for medical schools, adjusted secondary revenue data was analyzed using AAMC and Liaison Committee on Medical Education (LCME) financial data from 2009. Linear regression analysis was used to determine average fixed costs and variable cost per student in USD. RESULTS: In USD, $62,877 represents the best point estimate of the annual variable cost of educating a medical student. CONCLUSION: Comparing this cost to current tuitions and fees of LCME-accredited medical schools suggests that revenues other than tuition are needed to cover increases in class size. Tuition and fees revenue from increasing enrollment will not increase overall revenue to medical schools.

Effect of illness severity and comorbidity on patient safety and adverse events.

The objective was to investigate the effect of admission health status on hospital adverse events and added costs. Secondary data were from merged administrative and clinical sources for Mayo Clinic Rochester, Minnesota hospital discharges in 2005 (N = 60,599). This was a retrospective cross-sectional study of the effect of demographics, diagnosis group, comorbidity, and admission illness severity on adverse events, incremental costs, and length of stay (LOS) using the Agency for Healthcare Research and Quality Patient Safety Indicators and provider-reported events with harm. Estimates are derived from generalized linear models. Admission severity increased the likelihood of all types of adverse events (7.2% per unit acute physiology score for any event); 7 specific comorbidities were associated with increased events and 2 with decreased events. High admission severity increased incremental costs and LOS. Selected comorbidities increased incremental LOS but had no significant effect on incremental costs. Adverse event reporting should incorporate comorbidity and admission severity. Reimbursement incentives to improve patient safety should consider adjustment for admission health status.

Use of the emergency department for less-urgent care among type 2 diabetics under a disease management program.

BACKGROUND: This study analyzed the likelihood of less-urgent emergency department (ED) visits among type 2 diabetic patients receiving care under a diabetes disease management (DM) program offered by the Louisiana State University Health Care Services Division (LSU HCSD). METHODS: All ED and outpatient clinic visits made by 6,412 type 2 diabetic patients from 1999 to 2006 were extracted from the LSU HCSD Disease Management (DM) Evaluation Database. Patient ED visits were classified as either urgent or less-urgent, and the likelihood of a less-urgent ED visit was compared with outpatient clinic visits using the Generalized Estimating Equation methodology for binary response to time-dependent variables. RESULTS: Patients who adhered to regular clinic visit schedules dictated by the DM program were less likely to use the ED for less urgent care with odds ratio of 0.1585. Insured patients had 1.13 to 1.70 greater odds of a less-urgent ED visit than those who were uninsured. Patients with better-managed glycated hemoglobin (A1c or HbA1c) levels were 82 times less likely to use less-urgent ED visits. Furthermore, being older, Caucasian, or a longer participant in the DM program had a modestly lower likelihood of less-urgent ED visits. The patient's Charlson Comorbidity Index (CCI), gender, prior hospitalization, and the admitting facility showed no effect. CONCLUSION: Patients adhering to the DM visit guidelines were less likely to use the ED for less-urgent problems. Maintaining normal A1c levels for their diabetes also has the positive impact to reduce less-urgent ED usages. It suggests that successful DM programs may reduce inappropriate ED use. In contrast to expectations, uninsured patients were less likely to use the ED for less-urgent care. Patients in the DM program with Medicaid coverage were 1.3 times more likely to seek care in the ED for non-emergencies while commercially insured patients were nearly 1.7 times more likely to do so. Further research to understand inappropriate ED use among insured patients is needed. We suggest providing visit reminders, a call centre, or case managers to reduce the likelihood of less-urgent ED visit use among DM patients. By reducing the likelihood of unnecessary ED visits, successful DM programs can improve patient care.

Evaluation and prediction of health-related quality of life for total hip replacement among Chinese in Taiwan.

The objective of this study was to examine and predict the time trend of health-related quality of life (HRQoL) after total hip replacement (THR). A total of 383 patients receiving primary THR at two medical centers in Taiwan during 1997 to 2000 were enrolled for the study. Face-to-face interviews were conducted by using physician-rated Harris hip score and patient-reported short-form 36-item health survey (SF-36) immediately before the surgery and at 3, 6, 12, 24, and 60 months after surgery. Data analysed by piecewise linear regression revealed remarkable improvements in HRQoL dimensions at the third month after surgery and kept improving until the threshold level of from 39 months to 81 months, at which it reached a plateau. Role limitations due to physical and emotional problems and social functioning after surgery saw the most remarkable improvements, which appear to be related to improvements in functioning in many other dimensions of health. Such interdependence of the dimensions should be examined carefully to see if improvements in social roles can help improve the overall HRQoL in a more effective manner. The results should be applicable to other hospitals in Taiwan and in other countries with similar social and cultural practices.

Impact of diagnosis-timing indicators on measures of safety, comorbidity, and case mix groupings from administrative data sources.

CONTEXT: Many attempts to identify hospital complications rely on secondary diagnoses from billing data. To be meaningful, diagnosis codes must distinguish between diagnoses after admission and those existing before admission. OBJECTIVE: To assess the influence of diagnoses at admission on patient safety, comorbidity, severity measures, and case mix groupings for Medicare reimbursement. DESIGN: Cross-sectional association of various diagnosis-based clinical and performance measures with and without diagnosis present on admission. SETTING: Hospital discharges from Mayo Clinic Rochester hospitals in 2005 (N = 60,599). PATIENTS: All hospital inpatients including surgical, medical, pediatric, maternity, psychiatric, and rehabilitation patients. About 33% of patients traveled more than 120 miles for care. MAIN OUTCOME MEASURES: Hospital patient safety indicators, comorbidity, severity, and case mix measures with and without diagnoses present at admission. RESULTS: Over 90% of all diagnoses were present at admission whereas 27.1% of all inpatients had a secondary diagnosis coded in-hospital. About one-third of discharges with a safety indicator were flagged because of a diagnosis already present at admission, more likely among referral patients. In contrast, 87% of postoperative hemorrhage, 22% of postoperative hip fractures, and 54% of foreign bodies left in wounds were coded as in-hospital conditions. Severity changes during hospitalization were observed in less than 8% of discharges. Slightly over 3% of discharges were assigned to higher weight diagnosis-related groups based on an in-hospital complication. CONCLUSIONS: In general, many patient safety indicators do not reliably identify adverse hospital events, especially when applied to academic referral centers. Except as noted, conditions recorded after admission have minimal impact on comorbidity and severity measures or on Medicare reimbursement.

A U.S. perspective on AHSCs: a future of increased diversification.

Academic Health Sciences Centres (AHSCs) have long been viewed much as the historic battleship - possessing great force, power and bulk, but increasingly vulnerable to forays of lighter and more agile competitors. This commentary reviews the efforts of leaders of AHSCs in the United States to reposition their institutions at the centre of integrated delivery systems, partly as a result of greatly increased reliance on clinical revenue to support the historic teaching mission. While Lozon and Fox point to increased involvement of AHSCs in broad regional systems of care financed through a coordinated strategy, integrated systems in the United States may be fragmenting as marketplace-driven financial schemes actually discourage integrated care. From the perspective of organizational theory, the future seems to imply a diversification of organizational forms for the AHSCs in the United States, with a corresponding strategy of lessening reliance on clinical revenues through enhancement of research funding.